Provider Demographics
NPI:1285873448
Name:WEIGAND, ANDREA R (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:WEIGAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:R
Other - Last Name:HEVERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:848 S LA CASSIA DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2253
Practice Address - Country:US
Practice Address - Phone:208-344-0086
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1161363A00000X
MI5601005914363AM0700X
IDPA-2785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005914OtherSTATE OF MICHIGAN
NV1161OtherNV PA LICENSE #